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341. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47586/psn-pdf
     March 20, 2019 - Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative … Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Intraoperative … https://psnet.ahrq.gov/issue/wrong-patient-blood-transfusion-error-leveraging-technology-overcome- human-error … https://psnet.ahrq.gov/issue/wrong-patient-blood-transfusion-error-leveraging-technology-overcome-human-error … https://psnet.ahrq.gov/issue/wrong-patient-blood-transfusion-error-leveraging-technology-overcome-human-error

342. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865883/psn-pdf
     May 15, 2024 - Addressing electronic health record contributions to diagnostic error. … https://psnet.ahrq.gov/issue/addressing-electronic-health-record-contributions-diagnostic-error Design … This piece explores the lack of knowledge regarding the intersection of EHRs and diagnostic error. … https://psnet.ahrq.gov/issue/addressing-electronic-health-record-contributions-diagnostic-error https … https://psnet.ahrq.gov/issue/electronic-health-record-use-issues-and-diagnostic-error-scoping-review-and-framework

343. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865704/psn-pdf
     May 01, 2024 - Supporting error management and safety climate in ambulatory care practices: the CIRSforte study. … Supporting error management and safety climate in ambulatory care practices: the CIRSforte study. … https://psnet.ahrq.gov/issue/supporting-error-management-and-safety-climate-ambulatory-care-practices … This study evaluated an error management and safety climate intervention implemented across 184 ambulatory … The intervention included email newsletters on error management, e-learning modules to improve team

344. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44657/psn-pdf
     November 11, 2015 - Understanding and confronting our mistakes: the epidemiology of error in radiology and strategies for … error reduction. … error reduction. … https://psnet.ahrq.gov/issue/understanding-and-confronting-our-mistakes-epidemiology-error-radiology-and-strategies-error … https://psnet.ahrq.gov/issue/understanding-and-confronting-our-mistakes-epidemiology-error-radiology-and-strategies-error

345. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34691/psn-pdf
     May 18, 2016 - Error in medicine. May 18, 2016 Leape L. Error in medicine. JAMA. 1994;272(23):1851-1857. … https://psnet.ahrq.gov/issue/error-medicine Leape discusses how traditional methods of error reduction … With reference to Reason, he briefly reviews the cognitive psychology of human error, distinguishing … between performance and error at the schematic or "skill" level, where an error is a "slip" (or "lapse … "), and at the rule-based or "knowledge" level, where an error is a "mistake."

346. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/841156/psn-pdf
     October 10, 2010 - “Those found responsible have been sacked”: some observations on the usefulness of error. … “Those found responsible have been sacked”: some observations on the usefulness of error. … https://psnet.ahrq.gov/issue/those-found-responsible-have-been-sacked-some-observations-usefulness- error … https://psnet.ahrq.gov/issue/new-view-human-error-origins-ambiguities-successes-and-critiques https: … /issue/human-error https://psnet.ahrq.gov/issue/role-error-organizing-behaviour

347. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42238/psn-pdf
     July 02, 2014 - Teaching medical error disclosure to physicians-in- training: a scoping review. … Teaching medical error disclosure to physicians-in-training: a scoping review. … an error has occurred, many physicians choose their words carefully—failing to explicitly describe … the error, acknowledge responsibility, or express sympathy to patients. … A difficult case of error disclosure is discussed in an AHRQ WebM&M commentary.

348. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42067/psn-pdf
     March 18, 2013 - Methodological variations and their effects on reported medication administration error rates. … Methodological variations and their effects on reported medication administration error rates. … errors: variations in the methods used to measure errors can result in widely differing estimates of error … series of recommendations for standardizing measurement and reporting of medication administration error … rates, and medication error measurement standards have been developed for medication reconciliation

349. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49680/psn-pdf
     March 01, 2013 - This kind of error can be difficult to identify because it can be confused with other error types, such … The error classification system above was proposed to improve measurement of error rates, clinical impact … Error prevention requires a multifaceted approach. … Additionally, using root cause analysis to identify sources of error has proven to decrease error.(11 … Error types in anatomic pathology.

350. Action needed to prevent dangerous heparin-insulin confusion. | PSNet
     psnet.ahrq.gov/issue/action-needed-prevent-dangerous-heparin-insulin-confusion
     May 07, 2018 - June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

351. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38142/psn-pdf
     April 30, 2014 - Medical error disclosure among pediatricians: choosing carefully what we might say to parents. … Medical Error Disclosure Among Pediatricians. … https://psnet.ahrq.gov/issue/medical-error-disclosure-among-pediatricians-choosing-carefully-what-we- … might-say-parents Studies of medical error disclosure have demonstrated that, while physicians support … In this study, pediatricians were presented with error scenarios and asked to describe what they would

352. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49409/psn-pdf
     July 01, 2003 - Human error in medicine: a frontier for change. In: Bogner, MS, ed. Human error in medicine. … Stretching the search for the “why” of error: the systems approach. … Identifying error provoking factors: the systems approach. … The systems approach analysis of error. … Error reduction as a systems problem. In: Bogner MS, ed. Human error in medicine.

353. Pathologic Mistake | PSNet
     psnet.ahrq.gov/web-mm/pathologic-mistake
     February 15, 2010 - This kind of error can be difficult to identify because it can be confused with other error types, such … The error classification system above was proposed to improve measurement of error rates, clinical impact … Error prevention requires a multifaceted approach. … Additionally, using root cause analysis to identify sources of error has proven to decrease error.( 11 … Error types in anatomic pathology.

354. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39457/psn-pdf
     April 12, 2011 - Disclosure of medical error to parents and paediatric patients: assessment of parents' attitudes and … Disclosure of medical error to parents and paediatric patients: assessment of parents' attitudes and … https://psnet.ahrq.gov/issue/disclosure-medical-error-parents-and-paediatric-patients-assessment-parents … narrative-review-do-state-laws-make-it-easier-say-im-sorry https://psnet.ahrq.gov/issue/parental-preferences-error-disclosure-reporting-and-legal-action-after-medical-error-care … https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure

355. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43447/psn-pdf
     November 20, 2015 - Evaluating the effect of safety culture on error reporting: a comparison of managerial and staff perspectives … Evaluating the effect of safety culture on error reporting: a comparison of managerial and staff perspectives … https://psnet.ahrq.gov/issue/evaluating-effect-safety-culture-error-reporting-comparison-managerial-and … - staff-perspectives Voluntary error reporting is a critical mechanism for identifying patient safety … Error feedback and organizational learning were most associated with perceptions of frequent error reporting

356. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36536/psn-pdf
     January 10, 2011 - What do family physicians consider an error? … What do family physicians consider an error? A comparison of definitions and physician perception. … The investigators conducted surveys and literature review to explore how family physicians identified error … and found little agreement on what constituted error both in the field and the research base. … https://psnet.ahrq.gov//#error

357. Spotlight Case July 2008 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
     May 01, 2011 - Spotlight Case July 2008 Spotlight Case Duty to Disclose Someone Else’s Error * * Source and … A 62-year-old woman with skin cancer who experienced wrong-site surgery: review of medical error. … Liability claims and costs before and after implementation of a medical error disclosure program. … Talking with Patients and Families about Medical Error: A Guide for Education and Practice. … , optimal strategies involve full collaboration in error investigation and joint disclosure if an error

358. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49450/psn-pdf
     June 01, 2004 - The Wrong Shot: Error Disclosure June 1, 2004 Gallagher TH, Levinson W. … The Wrong Shot: Error Disclosure. PSNet [internet]. 2004. … When a harmful error takes place, patients first want an explicit, jargon-free statement that an error … Institutions can take several steps to improve error disclosure. … Moral courage in medicine--disclosing medical error.

359. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44390/psn-pdf
     July 18, 2016 - Pediatricians' attitudes toward error disclosure. … Pediatricians' Attitudes Toward Error Disclosure. … errors to patients is considered the standard of care, but many physicians remain uncomfortable with error … This survey study sought to assess pediatricians' perceptions of error disclosure to patients and their … with parents in choosing to disclose errors to children and believed parents should be present during error

360. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35839/psn-pdf
     March 28, 2011 - Patient assessments of a hypothetical medical error: effects of health outcome, disclosure, and staff … Patient assessments of a hypothetical medical error: effects of health outcome, disclosure, and staff … https://psnet.ahrq.gov/issue/patient-assessments-hypothetical-medical-error-effects-health-outcome- … disclosure-and-staff This study presented a medication error scenario to a group of recently discharged … https://psnet.ahrq.gov//#error